The current Incident Command System developed out of difficulties faced by firefighters four decades ago. During the 1970s, a series of forest fires ravaged southern California threatening populated areas. Despite adequate resources and personnel, many people were injured or killed and significant property damage was sustained.^1,2 Out of tragedy came the defined need for a better, more systematic approach.

• 
  

  Review the history of the creation of ICS.

  
  
• 
  

  Describe NIMS and its relation to ICS and disaster response.

  
  
• 
  

  Discuss the attributes and benefits of ICS.

  
  
• 
  

  Outline the structure of ICS and positions within ICS with a special focus on roles pertinent to a physician.

Reviews of the events and management of the tragic California fires of the 1970s revealed several significant problems. Multiple organizations were forced to work together during the incidents. They typically had disparate organizational structures which made establishing and maintaining leadership problematic. Too many workers were reporting to one supervisor, leading to an unwieldy span of control. Planning and resource allocation were poorly coordinated within and between organizations. Intra-agency communication was not well established, and differences in terminology used by various agencies led to misunderstandings and vague reporting.³ Incident information was unreliable and incident objectives were nonspecific.⁴ Overall, it was resource and personnel management and organization which contributed to failures during the incidents, and firefighter leadership worked to change these problems.

FIRESCOPE

Fire Fighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE), a cooperative task force between local, state, and federal agencies, developed the seeds of the current Incident Command System.

INCIDENT COMMAND SYSTEM

The Incident Command System (ICS) is an organizational and management tool utilized during disaster situations and emergency response operations. FIRESCOPE recognized the need for a system to coordinate the multiple organizations responding to an incident. The system would need to be capable of incorporating agencies from diverse geographical locations with varying skills and leadership structures. It would need to use language and positions which could be universally recognized by the group. A management structure based on the division of labor emerged, and while there have been several versions of ICS, the basic principles and attributes remain essentially unchanged. As it became recognized that the characteristics of wildfire fighting paralleled many of the characteristics of other disasters, ICS began to be applied more widely. It is now considered the standard among emergency management and its utilization is strongly encouraged by the federal government. The Hospital Incident Command System has developed from the core of the original ICS retaining many of its attributes. EMS physicians may encounter ICS while responding to a major disaster or while working in their own emergency departments. EMS physicians must be aware of the properties and structure of ICS and which positions they may be called upon to fill. They must also be advocates for the utilization of ICS as the national standard in emergency services delivery.

NATIONAL INCIDENT MANAGEMENT SYSTEM

In addition, ICS is a critical component of the National Incident Management System (NIMS). NIMS was designed in order to enable multiple agencies from different jurisdictions to work together during emergencies or disasters. NIMS is both flexible, as it is adaptable to incidents of all type and scale, and extremely structured in order to coordinate the incident management.⁵ In the wake of the terrorist attacks of 2001 and the hurricane seasons of 2004 and 2005, the federal government recognized the importance of intra-agency coordination and made this a priority in homeland security. NIMS is a national guideline for managing emergency incidents based on five components: preparedness, communication and information management, resource management, command and management, and ongoing management and maintenance.⁶ ICS, multiagency coordination systems, and public information are the elements which form the command and management component.

HOMELAND SECURITY PRESIDENTIAL DIRECTIVE 5

Homeland Security Presidential Directive 5, issued in March 2004, requires all federal departments and agencies to utilize NIMS. Compliance with NIMS became a condition for federal preparedness assistance.

THE NATIONAL RESPONSE FRAMEWORK

The National Response Framework (NRF) is an additional component of national disaster response planning. The NRF replaced the former National Response Plan. NRF is not an operational plan, but as its name suggests, a framework to guide responses to disasters and incidents of national significance. It is a blueprint which delineates the nation’s response efforts. The principles of the NRF enable the country to respond to an emergency in a coordinated fashion. While NIMS outlines the approach to managing an incident, NRF describes the principles which enable a unified national approach to a disaster. NRF is intended to be an “all-hazards” model, so that it may be utilized in responding to any type and size incident from small scale to large. The five fundamental principles of NRF are engaged partnerships, tiered response, scalable, flexible, and adaptable operational capabilities, unity of effort through unified command, and readiness to act (NRF Web site). NRF also provides Emergency Support Function Annexes, which provide operational and procedural guidance based on the type of resource. ESF #8, Public Health and Medical Services, incorporates medical and mental health.

With the development of ICS, 14 beneficial characteristics emerged. These factors often improved upon flaws in prior incident management (Box 74-1).

COMMON TERMINOLOGY

Establishing common terminology enables diverse entities from different specialties and jurisdictions to communicate effectively. It eliminates problems of group-specific lingo or terms and regional slang. Organizational positions and functions as well as resource descriptions are referred to by universal terms.

MODULAR ORGANIZATION

The organizational structure of the ICS develops based on the size, type, and complexity of the incident. It develops from the top down and can adapt to meet the needs of all types of hazards. Since it is expandable, it is able to change or grow depending on the nature of the incident. ICS should be employed even at smaller incidents. One issue with implementing ICS is that many providers feel uncomfortable with the principles and have little experience within the system. Frequently using and training with ICS facilitates its use in a larger or more complex emergency.⁷

MANAGEMENT BY OBJECTIVES

ICS requires that overall incident objectives and specific assignments and plans be developed. Objectives should be measurable and strategies to achieve those objectives must be created. Results must be documented to monitor progress.

INCIDENT ACTION PLANNING

Incident action planning refers to the process of communicating the overarching objectives for the incident. The incident action plan (IAP) refers to the formal documentation of the incident objectives. Priorities, tactics, and strategies will be included.⁸

MANAGEABLE SPAN OF CONTROL

Span of control emerged as a significant issue during the wildfires in southern California in the 1970s. The current ICS model limits the span of control for each individual position. The ideal span of control is three to seven subordinates. A larger span of control becomes unmanageable, contributing to poor leadership and supervision.

INCIDENT FACILITIES AND LOCATIONS

Specific types of facilities are designated by the ICS as well as suggested locations. Common facilities include the Incident Command Post, where the command staff centralize, and bases and camps for resources and personnel. Other facilities such as staging areas and triage areas may be established as the incident demands.

COMPREHENSIVE RESOURCE MANAGEMENT

Resource management is a critical element of incident management. Every resource, including personnel, and its utilization must be documented and its status kept current. Comprehensive resource management enables effective functioning at the incident and aids leadership in deciding the best manner in which to use resources. It assists in planning strategies for long-term events and cuts wastefulness.

INTEGRATED COMMUNICATIONS

Communications are designed to be interoperable and a plan to coordinate communications is created. Errors based on lack of information or miscommunications are decreased, and the response team functions more smoothly when all sectors remain well informed.

ESTABLISHMENT AND TRANSFER OF COMMAND

The initial establishment of command is paramount to the entire response effort. The primary response team is usually the first to take command. Systems for establishing command and how and when to transfer that command are necessary. Command may be transferred when more qualified individuals or services arrive or when the nature of the incident changes. A briefing process is standard when command needs to be transferred. ICS very clearly prescribes the process of formally transferring command.

CHAIN OF COMMAND AND UNITY OF COMMAND

Relationships are clearly delineated in the ICS which is a hierarchical system.⁹ Chain of command refers to the ranking of personnel within the system. Each individual has a specific position within the organization with an orderly line of authority. Unity of command means that each individual has one and only one supervisor. Therefore, each person knows from whom he or she should be receiving orders and to whom he or she should report. These specific lines of authority reduce confusion among personnel and ensure that all orders are generated from the top of the chain and work their way down. Within ICS all decision making and commands are from the top down. Information tends to be collected by those on the ground and works its way from the bottom up.